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Paediatric Ketamine Guideline

ROYAL DEVON & EXETER EMERGENCY DEPARTMENT

Paediatric sedation may only be performed by accredited ED doctors
Patient label
/ Age (y/m):
Consultant: / Wt (kg) = (age+4 x2):
Procedure being performed:
SUTURINGMANIPULATION REMOVAL OF FOREIGN BODY
OTHER, please describe:

Stop! Think! Have you considered:

  • Does the child simply need analgesia and reassurance?
  • Distraction techniques (with a trained nurse or play therapist)?
  • Adrenaline cocaine gel for wounds (contraindicated when near or involving mucous membranes)?
  • Nitrous oxide / mixer?
  • Intranasal diamorphine where the child is clearly in significant pain?
  • Is there another ED middle grade or consultant covering the department whilst you sedate? If not consider admitting the child for general anaesthetic.

Contraindications:
Age less than 12 months due to an increased risk of laryngospasm and airway complications. Children aged between 12 and 24 months should only receive ketamine sedation from expert staff (usually a consultant)
Eaten within the last 4 hours; consider risk/benefit in non-fasted clinically urgent cases.
Proposed procedure within the mouth or pharynx
A high risk of laryngospasm (active respiratory infection, active asthma)
Unstable or abnormal airway. Tracheal surgery or stenosis.
Active respiratory disease
Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems
Significant cardiac disease (angina, heart failure, malignant hypertension)
Significant head injury or reduced level or consciousness
Intracranial hypertension with CSF obstruction
Intra-ocular pathology (glaucoma, penetrating injury)
Previous psychotic illness
Uncontrolled epilepsy
Hyperthyroidism or Thyroid medication
Porphyria
Prior adverse reaction to Ketamine
Medical history
Drug history
Procedure
  • Have you used the Timeout Guideline
  • Contraindications checked

Procedure and complications explained to parents (laryngospasm and need for intubation 0.02%, moderate/severe agitation 1·5%, vomiting 7%, airway problems 1·5%, nystagmus and purposeless movements normal)
  • Written or verbal consent obtained (tick):
  • Calculated rescue suxamethonium dose 2mg/kg IV (tick): or 4mg/kg IM (tick):
  • Calculated tracheal tube size ((age + 4)/4) (tick):
  • All anaesthesia will take place in Resus

  • A minimum of 3 people (total) must be present while the sedation takes place:-

Person 1 / Sedator: / A consultant emergency physician or approved middle grade (with a duty consultant in the department). They may delegate to an appropriately trained nurse after 20 minutes if patient stable. Observes the patient and is responsible for maintaining the airway and monitoring
Person 2 / Nurse: / Ensures documentation of oxygen saturation, respiratory rate, heart rate and sedation score at 5-minute intervals
Person 3 / Operator: / Performs the procedure. Stops at any time if instructed to by sedator
Ketamine
  • Encourage the child and parents to talk (dream) about happy topics. This helps minimise unpleasant emergency phenomena
  • Onset:1-2 minsOffset:20-45 mins
  • Dose: 1mg/kg ketamine IV over no less than 1 min. Consider 2.5mg/kg IM ketamine where IV cannulation has not been achieved or is predictably difficult.Caution: note there are different formulations of ketamine available (10mg/ml & 100mg/ml)
Repeated 0·5 mg/kg IV incremental ketamine doses may be given if inadequate sedation at 5 minutes or longer anaesthesia required. Consider 1 mg/kg as a supplemental dose via the IM route
Date:
Time:
Dr undertaking sedation:
Dr undertaking procedure:
Nurse: / Monitoring and equipment
Basic airway equipment (Guedel, bag-valve-mask, suction, oxygen etc.)
Advanced airway equipment (tracheal tubes, catheter mount, ties, bougies, etc.)
Emergency resuscitation drugs (adrenaline, atropine, naloxone)
Suxamethonium/Defibrillator/ECG monitor all available
Pulse oximeter – continuous until recovery well established
Nasal capnography continuous once sedated
Drapes positioned so that airway and chest wall motion visible
Time (s) /
Ketamine dose (state IV or IM)
Other drugs
Conscious level (AVPU)
O2 l/min
SpO2 %
ECG sinus / ectopics etc
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
15
10
5
COMPLICATIONS (please detail problems was it eventful/uneventful): / Sentinel risk descriptors
  • Oxygen desaturation, severe(<75% at any time) or prolonged (<90% for>60s)
  • Apnoea, prolonged (>60s)
  • Cardiovascular collapse/shock (clinical evidence of inadequate perfusion)
  • Cardiac Arrest/Absent pulse
/ Sentinel intervention
  • Chest compressions
  • Tracheal intubation or the admintation of:
  • Neuromuscular block
  • Metaraminol/adrenaline
  • Atropine to treat bradycardia
Sentinel outcome
  • Aspiration

Post-procedure
  • Patient satisfaction score 0 (worst) -10 (best) on return to baseline mental status asked by nurse
  • Patient comments

  • All patients should be monitored in the paediatric resus room until they start to respond to vocal stimuli

  • Minimal physical contact or disturbance (advise parents not to stimulate child prematurely)

  • Quiet with dim lighting
  • Expect recovery to be complete between 60 & 120 minutes

Discharge criteria
  • Patient can ambulate at pre-procedure level

  • Patient has minimal pain or nausea & vomiting (should not eat or drink for 2 hours post ketamine)

  • Patient has a responsible adult to escort them and stay with them at home

  • Parents advised not to give any other sedative (e.g. phenergan) but that simple analgesics are fine (paracetamol, ibuprofen)

  • Parents are advised to contact ED if they have any concerns

  • Advice leaflet given to parents

Sedating Consultant signature: / Consultant name: / Date:
Nurse signature: / Nurse name / Date:

Paediatric Sedation/GL//EF/30.09.2015